THIEME 36 Techniques in Neurosurgery

Different Methods and Technical Considerations of Decompressive Craniectomy in the Treatment of Traumatic Brain Injury: A Review

Amit Kumar Ghosh1

1 Global Heath City Chennai, Chennai, Tamil Nadu, India Address for correspondence Amit Kumar Ghosh, DNB, Embassy Residency, Perumbakkam, Saraswati-Rajasekhar Salai, Chennai, Tamil Indian J Neurosurg 2017;6:36–40. Nadu 600100, India (e-mail: [email protected]).

Abstract Decompressive craniectomy, which is performed worldwide for the treatment of severe traumatic brain injury (TBI), is a surgical procedure in which part of the skull is removed to allow the brain to swell without being squeezed. On 1901, Kocher was the Keywords first surgeon to promote surgical decompression in posttraumatic brain swelling. In ► decompressive this article, different methods of decompressive craniectomy and its technical craniectomy considerations have been reviewed.

Introduction allowed this technique to be accepted as a recommended therapy for refractory ICP. At present, the European Brain The first decompressive craniectomy was presented by Kocher Injury Consortium and Brain Trauma Foundation guidelines

on 1901,1,2 followed by Cushing in 19053 and Horsley in for severe TBIs recommend decompressive craniectomy as a 1906.2 However, because of unpleasant aesthetic results, the treatment for refractory intracranial hypertension that procedure lost its general acceptance.2 does not respond to medical therapeutic measures.5,6 In traumatic brain injury (TBI), the benefit of this procedure Concept of decompressive craniectomy is related to the has been agreed as well as disagreed. In 1940, Erlich suggested Monro-Kellie doctrine. The brain is a soft organ housed in a decompressive craniectomy for all head injuries with stiff box (the skull). Apart from the brain substance, this box persistent coma for more than 24 hours.2 Rowbotham also houses arterial and venous blood and cerebrospinal (1942) recommended decompressive craniectomy for all fluid (CSF). Any increase in any one of these components will patients for whom medical treatment was ineffective for result in a shift of any other component from the box or first 12 hours.2 During 1960 to 1970, Mayfield, Moody, Lewin increased pressure within the box (ICP). Decompressive presented papers noting high mortality with this procedure craniectomy is performed to increase the size of the box so discouraging its use.2 that the extra volume can be accommodated. Thus “a After the introduction of computed tomographic (CT) lifesaving procedure.” scan on 1975, Ramshoff, Morantz presented decompressive craniectomy in series of comatose patients with traumatic Different Methods of Decompressive acute subdural hematomas with 40% survival rate and 27% Craniectomy in the Treatment of TBI back to normal life.2 However, the method still did not get general approval. Different methods of craniectomies have been described which The credit of rediscovering the benefit of decompressive include circular decompression, subtemporal craniectomy craniectomy goes to Guerra et al4 in 1999 who published (Cushing), large fronto-temporoparietal decompressive their 20 years results of decompressive craniectomies using craniectomy (standard trauma craniectomy), bifrontal CT scan and intracranial pressure (ICP) monitoring in craniectomy, large fronto-temporal or temporo-parietal Journal of Neurosurgery. His evidence-based good results craniectomy, and hemispheric craniectomy.7,8

received DOI http://dx.doi.org/ © 2017 Neurological Surgeons’ Society February 7, 2016 10.1055/s-0036-1584585. of India accepted ISSN 2277-954X. March 11, 2016 published online March 16, 2017 Decompressive Craniectomy for Treating TBI Ghosh 37

Circular decompression was unable to take effect because of the limited space.9 Subtemporal craniectomy the was introduced by Cushing1,3 involves removing the part of the skull beneath the temporal muscle by opening the dura.10 This procedure also gives inadequate decompression effect.11 Furthermore, this procedure may lead to temporal lobe herniation and necrosis.11 At present, the more widely used methods include large unilateral frontotemporoparietal craniectomy/hemisphere craniectomy for lesions or swelling confined to one cerebral hemisphere, and bifrontal craniectomy from the floor of the anterior cranial fossa to the coronal suture to the pterion for diffuse swelling.7,11 Large decompressive craniectomies, including frontotemporoparietal/hemisphere craniectomy and bifrontal craniectomy, seemed to lead to better outcomes in patients with severe TBI compared with other varieties of surgical decompression in previous literature,4,8,12 The most direct proof was provided by Jiang et al8:a Fig. 1 Classic “question mark” trauma flap.2 prospective, randomized, multicenter trial suggested that large frontotemporoparietal decompressive craniectomy (standard trauma craniectomy) significantly improved the Burr holes can be placed to the pterion, temporal bone, and outcome in severe TBI patients with refractory intracranial posterior parietal and frontal regions, as close as possible to the hypertension, compared with routine temporoparietal scalp incision, taking advantage of the whole skin flap. Then, craniectomy, and had a better effect in terms of decreasing the underlying bulging dura is carefully stripped off the bone, in ICP.8 Munch et al found that large frontotemporoparietal all the burr holes with the use of a dissector. The burr holes are craniectomy could provide as much as 92.6 cm3 additional connected by using a Gigli saw or high-speed craniotome.7,16 space (median: 73.6 cm3).7,11 In bilateral hemicraniectomy, a bone ridge of approximately Decompressive craniectomy is sometimes combined with 3 to 4 cm in width is preserved over the superior sagittal a simultaneous lobectomy.13,14 However, this should be sinus.2,16 performed with caution because excessive excavation of In bifrontal decompressive craniectomy,16,20 abicoronalskin brain tissue may lead to poor results, though the ICP could flap is performed and a frontotemporal bone flap including the be reduced rapidly.13 bone over the superior saggital sinus is removed as a single piece. A key point of this procedure is the careful elevation of Technical Considerations the bone flap, which requires careful dissection of the underlying superior saggital sinus. A variant of bifrontal Scalp Incisions craniectomy implies preserving a frontal median bone over Different methods of scalp incisions2 have been described the superior saggital sinus.2 such as classic “question mark” flap (►Fig. 1), second optional flap (►Fig. 2), and bicoronal flap(►Fig. 3). Usually, the temporalis muscle is dissected along with scalp in one plane (osteoplastic flap), by using monopolar cautery. According to another technique, the temporalis muscle may be mobilized separately, and its fascia may be dissected and harvested for the duraplasty.7,15,16 Superficial temporal artery and the branches of the facial nerve always be tried to preserve during scalp and temporalis muscle elevation.15,16

Bone Removal The amount of bone removal in unilateral decompressive craniectomy has been described in RESCUEicp study,17 which is a wide craniectomy ( 12 cm in diameter) descending down to temporal fossa base and posteriorly up to asterion, and also has been described in Romanian Neurosurgery2 and some other studies.7,16,18,19 Key point of bone removal is to remove the bone up to middle cranial fossa base to decompress the temporal lobe and prevent uncal herniation, and also up to asterion 2 posteriorly.16,19 Fig. 2 Second optional flap.

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Fig. 3 Bicoronal flap.2

Dural Opening and Duraplasty but left the fascia base 1 to 2 cm long for the blood supply. Decompressive craniectomy, dural opening, and augmentative Finally, they turned the temporal fascia beneath the temporal duraplasty could maximize brain expansion and recommended muscle and sutured it to the dura. Four-flap duraplasty has by most authors.7,16 been described by Shima et al (►Fig. 7).19 It showed better outcome and lower incidences of Csókay et al7,23 described “vascular tunnel” method to secondary surgical complications such as brain herniation prevent brain herniation via the craniectomy defect that through the craniectomy defect, epilepsy, intracranial may lead to compression of vessels and result in ischemic infection, and CSF leakage through the scalp incision or necrosis of the portion of the herniated brain dural incisions

contralateral intracranial lesion compared with those who in a stellate fashion, and then keeping hemostatic sponge only underwent surgical decompression, leaving the dura supporting vessels in between the dura and brain. open.21 Keeping the dura open with no protection for the Another method, lattice duraplasty,24 was also introduced underlying brain tissue may increase the risk of these by Mitchell et al to avoid herniation of the brain through the complications.21 cranial defect. After conventional craniotomy, they made a The dura can be opened in a C-shaped fashion (►Fig. 4)or series of dural incisions, each 2 cm long and with 1-cm stellate fashion (►Fig. 5) or four-flap technique (►Fig. 6).2 intervals. The process was repeated in parallel rows of The dura is enlarged with the patient’s own tissue, such as incisions so that each incision in one row was adjacent to temporal fascia, temporal muscle, or galea aponeurotica or an intact dural bridge in the rows on either side. The same with artificial material.7 course was then performed, but in a direction vertical to the Yu et al7,22 described separation of the temporal deep initial incision. fascia from the temporal muscle to the zygomatic arch, and then cut the fascia from the base backward along the zygoma

Fig. 4 C-shaped dural opening. Fig. 5 Stellate.

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Fig. 8 Four-quadrant osteoplastic decompressive craniotomy by Peethambaran and Valsalmony.27

Fig. 6 Four-flap dural opening.19 Peethambaran and Valsalmony27 described a technique for decompressive craniectomy (►Fig. 8) to avoid revision cranioplasty after surgery by loosely suturing four pieces of Some Other Technical Modifications craniectomized bone with the skull. Vakis et al28 introduced a method to prevent peridural The “Tucci f lap” was suggested by Goettler and Tucci25 and fibrosis after decompressive craniectomy. Development of similar technique called “in situ hinge” craniectomy was multiple adhesions among the dura, temporal muscle, and introduced by Ko and Segan.”26 After decompressive galea would be a problem during subsequent cranioplasty, craniectomy, there is theoretical risk of injury to the and would also be a potentially deleterious factor for patient unprotected brain. Moreover, with the skin flap concavity, the recovery. To prevent adhesions, the authors placed a dural hydrodynamic disturbance of CSF circulation and the decrease substitute between the dural layer and galea aponeurotica in cortical perfusion hinder patient recovery. After craniotomy, after augmentative duraplasty with temporal muscle. removal of the intracranial lesion, and duraplasty, the bone flap To increase the space of decompressive craniectomy, was replaced and one side of the flap was attached to the Zhang et al29 suggested a method of surgical decompression cranium by plates. The plates act as a hinge that allows the combined with removal of the temporal muscle part. unattached portion of the bone flap to float out with bone However, survivors developed a higher rate of mastication swelling. disability. Bhat et al30 described multidural stabs or SKIMS-technique that showed that multiple incision of the dura in acute subdural hematoma drains the hematoma, relieves ICP rapidly, and avoids brain pouting and cortical lacerations during surgery.

Closure of Wound

Dural hitch stitches have been recommended to prevent extradural hemorrhage. Subgaleal suction drain can be given with low suction. Two layered (galea and skin) is always good for subsequent healing and also to prevent CSF leak.

Conclusion

A surgeon has to standardize his/her technique of decompressive craniectomy that is the most common lifesaving neurosurgical procedure according to available literature to give the maximum therapeutic decompression effect by removing adequate bone, relieving refractory ICP, and restoring cerebral blood flow, and also following the 19 Fig. 7 Four-flap duraplasty as shown by blue line. techniques to avoid subsequent complications.

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